Occupational Therapy’s Role in Schools: A Survey of Occupational Therapy Practitioners

Abstract

Importance: Limited evidence exists surrounding the diverse, multifaceted nature of responsibilities and challenges among school-based occupational therapy practitioners (SBOTPs).

Objective: To describe a service delivery model, feedback provision, intervention approaches, roles and responsibilities, and factors contributing to intervention decisions for SBOTPs.

Design: A descriptive electronic survey design with closed- and open-ended questions for January–March 2024.

Setting: School-based practice

Participants: Participants included 500 SBOTPs across the United States, with the majority having 10 or more years of experience (39.6%) and a master’s degree (58.9%).

Outcomes and Measures: Survey questions describing intervention approaches and frequency of use, service delivery methods, feedback provision, duties, and demographics.

Results: Most SBOTPs in elementary school provided direct intervention in therapy rooms (74.2%), whereas SBOTPs in middle and high school primarily provided consultative services (69% and 75.63%, respectively). Feedback was reported to be provided during required reports and meetings across all settings (86.27%, 88.7%, and 91.18%, respectively). The most frequently reported interventions used for SBOTPs in elementary and middle school addressed fine motor skills (98.6% and 69.5%, respectively), whereas those in high school primarily addressed life skills (56.5%). Reportedly, mental health and literacy participation were rarely addressed. Education, years of experience, and caseload size affected choices across all settings.

Conclusions and Relevance: This study clarifies the roles of U.S. SBOTPs, demonstrating how their expertise supports individual student needs and broader educational goals. By understanding and leveraging SBOTPs’ contributions, schools can better address their student populations’ diverse needs, ensuring the opportunity to succeed academically and socially.

Plain-Language Summary: This study describes a service delivery model, feedback provision, intervention approaches, roles and responsibilities, and factors contributing to intervention decisions for school-based occupational therapy practitioners. We asked 500 practitioners what interventions they use and how often, how they provide the interventions, how they communicate the child’s progress, and other tasks for which they are responsible across school settings. In elementary schools, participants said that they provide interventions in therapy rooms, whereas middle and high school practitioners consulted more with teachers and staff to support students. Our participants said that, primarily, they use fine motor and handwriting interventions in elementary and middle school but focus on developing life skills in high school. Few participants said that they address mental health or literacy, but research shows that they can and should. Many participants reported that they give feedback in required reports or meetings but wished that they had more time to provide regular feedback to students and families.

This study describes a service delivery model, feedback provision, intervention approaches, roles and responsibilities, and factors contributing to intervention decisions for school-based occupational therapy practitioners.

The American Occupational Therapy Association (AOTA) found that 18.8% of occupational therapy practitioners and 15.4% of occupational therapy assistants work in schools (AOTA, 2020). The primary role of a school-based occupational therapy practitioner (SBOTP) is to support students’ participation and success in the general education environment (Cahill & Bazyk, 2020). SBOTPs support students’ participation and success by addressing physical, sensory, cognitive, or psychosocial challenges that affect the student’s ability to access meaningful school occupations and benefit from their education (Cahill & Bazyk, 2020). Various meaningful school occupations include academic, nonacademic (e.g., sports, clubs, music), prevocational, and vocational activities (Cahill & Bazyk, 2020). Student occupations are influenced by developmental and age-related factors and contextually relevant factors such as routines (e.g., bus, recess), class schedules, and relationships with peers (Cahill & Bazyk, 2020; Clopper et al., 2024; Rodrigues & Seruya, 2019).

Numerous factors, including various federal and legal mandates, influence how SBOTPs support students’ participation in meaningful school occupations. In response to these mandates and efforts to promote the inclusion of students with disabilities, many schools have adopted multi-tiered systems of support (MTSS) and have embedded the response to intervention framework (RTI). Through the MTSS and RTI, SBOTPs have expanded their roles to include early identification, screening, prevention, targeted interventions, and intensive individual interventions (Cahill & Bazyk, 2020).

Many SBOTPs provide indirect supports for early identification, screening, and prevention, (e.g., observations in natural environments, environmental adaptations, teacher and staff education, or developing programming to support student’s needs; Cahill & Bazyk, 2020; Salazar Rivera et al., 2024). Targeted and intensive interventions should differ, depending on the students’ needs, challenges, and the meaningful occupations identified by the student, families, and educational team. However, there are clear themes in the focus of interventions provided by elementary SBOTPs present in the evidence base. Elementary SBOTPs are focused on improving handwriting, motor, visual–motor, attention, and behavior challenges (Grajo et al., 2020; Salazar Rivera et al., 2024). Research is less defined for SBOTPs in middle and high schools, but studies suggest that SBOTPs should support students’ transition readiness, social participation, fine motor and handwriting, assistive technology, literacy participation, and life skills (Clopper et al., 2024). Evidence is lacking to indicate whether each of these intervention foci are addressed by SBOTPs in middle and high schools, and some evidence suggests that they are not. Research suggests a mismatch between interventions provided and best practices. For example, SBOTPs address fine motor and handwriting skills despite the perceived lack of appropriateness for middle schoolers (Rodrigues & Seruya, 2019). Last, it is unclear whether SBOTPs are adequately addressing emerging intervention foci such as mental health and literacy (Cahill & Bazyk, 2020; Grajo et al., 2020).

Service delivery can occur in several places, ranging from therapy rooms (i.e., the “pull-out” approach) to the student’s natural environments (e.g., classroom, recess, lunch, school bus; i.e., the “push-in” approach; Cahill & Bazyk, 2020). Integrated services, or occupational therapy in a student’s natural context, has been found to be most effective for achieving new skills related to meaningful occupations (Cahill & Bazyk, 2020), yet SBOTPs report rarely using this approach because of barriers to implementing services in student’s natural contexts (Rodrigues & Seruya, 2019; Seruya & Garfinkel, 2020). Given the vast ways in which SBOTPs may support students in fully participating in their educational environment, there has been a push in the past decade to move from caseload approach to a workload approach (Seruya & Garfinkel, 2020). Workload refers to the diverse assortment of activities that SBOTPs may be engaged in to support students directly and indirectly as opposed to caseload, which accounts for the sheer number of students directly supported (Seruya & Garfinkel, 2020). Although it is a distinct concept, the workload model often supports integrated service delivery methods. However, evidence indicates that many SBOTPs still operate under a caseload service model (Seruya & Garfinkel, 2020).

Researchers have examined specific interventions that have been primarily reported to be used in elementary settings, yet little is known about the role of SBOTPs in middle and high schools. Factors such as setting, models (e.g., workload vs. caseload), service delivery (e.g., direct, indirect, consultative, collaborative), diverse student demands, and additional job responsibilities required of SBOTPs likely affect the role of each SBOTP. These factors, alongside evidence, suggest that SBOTPs are not using their full scope of practice (Clopper et al., 2024; Rodrigues & Seruya, 2019; Salazar Rivera et al., 2024).These findings can be used to further advocate for the many contributions of SBOTPs across settings (Rodrigues & Seruya, 2019). Despite AOTA’s best practice recommendations, SBOTPs face significant barriers to implementation. Understanding these challenges across settings is essential to addressing gaps. Therefore, the purpose of this study was to describe the role and responsibilities, service delivery models, intervention approaches, and feedback provision reportedly used by SBOTPs in the United States.

Method

An electronic Qualtrics survey was distributed to SBOTPs to describe their roles and contributions to supporting students in schools. This research was exempt from the Lincoln Memorial University Institutional Review Board.

Recruitment

SBOTPs were included in the study if they were practicing within the past year. Recruitment flyers and e-mails were distributed to all state occupational therapy associations within the United States, with 84% agreeing to disseminate the research information. Additional recruitment efforts included outreach to state educational departments, occupational therapist social media groups, and snowball sampling. Recruitment materials included a link to the electronic consent form in Qualtrics.

Survey Development

To develop the survey, the research team followed guidelines developed by the International Association for Health Professions Education and included a thorough literature review, literature synthesis, item development, and expert validation (Artino et al., 2014). Expert validation was conducted by disseminating a Qualtrics survey to 9 pediatric SBOTPs and academic researchers with expertise in survey design. Additional questions were included on this survey to ask the experts for their input on each question and their understanding of the question and responses, and to request any feedback to revise the survey before disseminating it to participants.

The final version of the survey included confirmation of eligibility and informed consent, the school setting(s) where participants practiced, interventions used, frequency of intervention use, service delivery method, feedback method, additional duties, and demographic characteristics (Appendix A.1 in the Supplemental Material, available online with this article at https://research.aota.org/ajot). Interventions used refers to the intervention categories that SBOTPs reported using for the students they served and were developed on the basis of the available literature on common school-based and/or best practices. Researchers separated certain intervention categories to better understand current practice (e.g., we asked about handwriting and literacy separately to understand whether SBOTPs primarily focused on handwriting as opposed to reading). Participants were offered an opportunity to report other interventions used in an open-ended response. Frequency of use was reported as never, annually, biannually, quarterly, monthly, weekly, or daily. Participants reported the most effective service delivery methods and most common feedback provision style by using multiple select answers, given that there may be more than one approach, depending on the individual child’s needs. Additional duties were reported using a sliding scale to determine the percentage of time participants spent on activities outside of direct care.

Data Collection

Eligible participants who provided consent were immediately directed to the survey in Qualtrics. The survey was administered from January to March 2024, and completion took 10 to 20 min.

Data Analysis

IBM SPSS Statistics (Version 29) was used for quantitative data analysis. We analyzed quantitative data using descriptive statistics, including frequency and percentage of interventions, service delivery, feedback methods, roles or responsibilities, and demographic characteristics. We calculated means and standard deviations to understand the average percentage of time spent in various areas (e.g., paperwork and documentation, individualized education program IEP] meetings). Cross-tabulations, including correlations, were run between interventions used and demographic characteristics.

We analyzed open-ended qualitative responses using content analysis with two analysts. Specifically, the analysts immersed themselves in the data, selecting the unit of analysis and engaged in open coding independently (Elo & Kyngäs, 2008). They met to discuss and finalize open codes, grouping codes together and generating categories (Elo & Kyngäs, 2008). Finally, one analyst reviewed all data using the final categories and subcategories, and the other analyst confirmed accuracy; and then frequency and percentage of codes were calculated.

Results

Most participants practiced in multiple settings, with 488 participants in elementary schools (98.3%), 354 in middle schools (79.7%), and 238 in high schools (56.5%). Most participants had more than 10 yr experience (30.8%), a master’s degree (45.6%), and 41 to 60 students on their caseload (41.9%). Participants practiced across the country. Detailed demographic characteristics are presented in Table 1.

Table 1.

Participant Demographics

Demographic Characteristic	Frequency	%
Time practicing, yr
<1	44	11.3
1–3	101	26.0
4–6	50	12.9
7–9	40	10.3
>10	154	39.6
Highest degree
Associate’s	22	5.7
Bachelor’s	50	12.9
Master’s	228	58.9
Clinical doctorate	47	12.1
Postprofessional doctorate	40	10.3
Student caseload, n
0–20	22	5.7
21–40	106	27.2
41–60	163	41.9
61–80	59	15.2
81–100	25	6.4
>100	14	3.6
Region
Northeast	121	28.7
Midwest	123	29.1
South	105	24.9
West	73	17.3

Participants reported various service delivery models. SBOTPs in elementary schools reported the most use of direct intervention in therapy rooms (74.2%), direct intervention in special education classrooms (66.4%), direct intervention in classrooms (64.5%), and consults (60.5%). SBOTPs in middle schools reported the most use of consults (69%), direct intervention in special education classrooms (57%), direct intervention in therapy rooms (52.3%), and direct intervention in classrooms (41%). SBOTPs in high schools followed a similar pattern as that of SBOTPs in middle schools who reported using consults (75.63%), direct intervention in special education classrooms (57.6%), direct intervention in therapy rooms (40.34%), and direct intervention in classrooms (34.5%). Open-ended responses revealed additional service delivery models, including staff training (9.7%), direct intervention in any open area (e.g., hallway, closet; 8.7%), groups (8.7%), other formats (telehealth, community, etc.; 7.8%), or MTSS (6.8%). For example, as one practitioner explained, was “no dedicated space with general education students,” so they practiced “where we can find space.” Another described their group and MTSS approaches by explaining that they conducted “small-group, RTI-type interventions provided for all students in classrooms.”

Participants reported using various methods to provide feedback to families; however, most reported using scheduled progress reports or IEP meetings (elementary school: 86.27%; middle school: 88.7%; high school: 91.18%). Participants rarely reported using scheduled phone calls (6.97%, 8.5%, and 7.56%, respectively), quarterly in-person parent conferences (3.44%, 13.6%, and 12.6%, respectively), or weekly summary reports by e-mail (3.28%, 2.6%, and 2.94%, respectively). Themes from open-ended comments included providing feedback when the child made progress or when needs arose (23.6%), providing feedback when parents explicitly requested it (16.3%), providing feedback to staff who would relay the information to families (7.4%), or providing feedback directly to the child (6.4%). Participants recognized that they should be providing more feedback to the families, but time constraints prohibited them from doing so (2%). One therapist explained this issue by reporting that they “wish it were more, but [there is] not enough time. My district refuses to staff [SBOTPs] equally to other service providers.”

Interventions regularly used were defined as those that were reported as being used weekly or daily. SBOTPs in elementary schools reported using fine motor (98.6%) and handwriting (95.8%) interventions, followed by self-regulation or executive function (EF) interventions (85.1%). Less than half of the SBOTPs in elementary schools reported utilizing mental health (49.1%) or literacy participation (41.9%) interventions. SBOTPs in middle schools reported using interventions daily less commonly, compared with SBOTPs in elementary schools, instead using most interventions monthly or weekly (Table 2). Of the interventions regularly used, SBOTPs in middle schools reported using fine motor (69.5%), self-regulation or EF (66.5%), assistive technology (AT; 61.6%), handwriting (59.8%), or life skills (58%) interventions. Less than half of the SBOTPs in middle schools used mental health (40%), transition readiness and/or prevocational (38.5%), or literacy participation (27.5%) interventions. SBOTPs in high schools also reported that they were more likely to use interventions monthly or weekly instead of daily. SBOTPs in high schools reported most using life skills (56.5%), self-regulation or EF (55%), or prevocational (54.3%) interventions; they reported rarely using handwriting (29.8%) or literacy participation (17.6%) interventions. Themes from open-ended comments included visual processing or visual–motor integration (38.9%), gross motor (12.3%) or biomechanical (e.g., stretching, range of motion; 3.2%), leisure participation (4%), keyboarding (4%), and academic participation (2.4%). Some participants explained how they may use sensory interventions for self-regulation but used them separately during other times and felt that they should have been a stand-alone option. Similarly, some participants reported that EF should have been a stand-alone option (10.3%).

Table 2.

Percentage of Interventions Used by OTPs Across Settings

School Level and Intervention	Use of Intervention (%)
	Never	Annually	Biannually	Quarterly	Monthly	Weekly	Daily
Elementary school
Fine motor	0.2	0.0	0.0	0.2	0.9	14.2	84.4
Social participation	8.3	1.4	0.7	3.9	12.8	38.1	34.9
Mental health	20.9	2.3	1.4	7.8	18.6	30.5	18.6
Handwriting	0.0	0.5	0.0	0.0	3.7	21.3	74.5
AT	4.6	1.6	0.7	8.0	22.2	43.3	19.5
Self-regulation or EF	1.1	0.2	0.5	2.3	10.8	33.5	51.6
Literacy participation	30.4	2.5	0.7	5.3	19.1	28.8	13.1
Life skills	3.0	0.7	1.6	5.1	23.4	44.4	21.8
Middle school
Fine motor	4.5	2.1	0.6	7.3	16	41.4	28.1
Social participation	14.8	4.5	2.1	6.6	20.2	34.7	16.9
Mental health	22.7	2.4	2.4	10.3	22.1	26.1	13.9
Handwriting	6.3	1.8	2.1	8.8	21.1	39	20.8
AT	6.6	1.8	1.8	7.9	20.2	41.7	19.9
Self-regulation or EF	3.6	1.2	0.9	9.7	18.1	40.5	26.0
Literacy participation	43.2	4.2	1.8	7.9	15.4	19.0	8.5
Life skills	7.3	2.1	0.6	11.2	20.8	39.3	18.7
Prevocational or transition	18.5	5.5	4.5	7.0	26.1	28.2	10.3
High school
Fine motor	13.7	5.6	1.3	11.2	24.0	27.9	16.3
Social participation	19.0	5.2	1.7	7.8	22.8	26.3	17.2
Mental health	28.8	5.2	1.3	9.9	21.5	21.5	12.0
Handwriting	27.6	6.5	3.0	12.5	20.7	22.0	7.8
AT	7.7	3.9	3.0	24.9	24.9	33.5	14.2
Self-regulation or EF	8.2	4.3	2.1	6.9	23.6	34.8	34.8
Literacy participation	52.8	3.4	1.3	9.9	15.0	13.7	3.9
Life skills	4.7	3.4	1.7	25.9	25.9	30.6	25.9
Prevocational	6.0	5.6	2.2	25.0	25.0	33.6	20.7
Transition	8.2	9.5	3.4	25.9	25.9	25.0	16.4

Note. AT = assistive technology; EF = executive function; OTP = occupational therapist practitioner.

We conducted cross-tabulations between interventions used and demographic characteristics (Table 3). SBOTPs in elementary schools were reportedly more likely to provide social participation (r = .106, p = .039), mental health (r = .168, p < .001), and life skills (r = .159, p = .002) interventions and reportedly less likely to provide handwriting (r = −.178, p < .001) interventions if they had been practicing longer. SBOTPs in elementary schools were reportedly less likely to address social participation if they had a bachelor’s or master’s degree, compared with a doctoral degree (r = −.112, p = .028). SBOTPs in middle schools were reportedly less likely to provide handwriting interventions if they had been practicing longer (r = −.201, p < .001) and reportedly less likely to provide literacy participation (r = −.113, p = .048) or life skills (r = −.148, p = .009) interventions if they had larger caseloads. SBOTPs in high schools were reportedly more likely to use AT (r = .015, p = .027); provide life skills interventions (r = .220, p = .001), prevocational interventions (r = .182, p = .007), and transition interventions (r = .251, p < .001) if they had a higher degree; and were reportedly less likely to provide life skills interventions if they had a larger caseload (r = −.201, p = .007).

Table 3.

Correlations Between Interventions Used and Demographic Characteristics Across Settings

School Level and Intervention	Years Worked		Highest Degree		Caseload
	Spearman’s ρ	p	Spearman’s ρ	p	Spearman’s ρ	p
Elementary school
Fine motor	−.077	.133	−.050	.328	−.005	.927
Social participation	.106	.039	−.112	.028 *	−.042	.410
Mental health	.168	<.001 *	−.083	.104	−.016	.755
Handwriting	−.178	<.001	−.017	.746	.025	.627
AT	.093	.069	.099	.054	.030	.558
Self-regulation or EF	.044	.392	−.025	.627	−.031	.550
Literacy participation	.101	.050	.000	.999	−.005	.930
Life skills	.159	.002 *	.016	.749	−.006	.902
Middle school
Fine motor	−.144	.011 *	−.019	.738	−.063	.268
Social participation	.042	.466	.032	.579	−.076	.186
Mental health	.091	.110	.025	.666	−.060	.291
Handwriting	−.201	<.001 *	−.052	.362	−.082	.150
AT	.090	.116	.083	.146	−.040	.488
Self-regulation or EF	−.030	.604	.077	.179	−.068	.237
Literacy participation	.070	.223	.036	.530	−.113	.048 *
Life skills	.060	.292	.087	.128	−.148	.009 *
Prevocational or transition	.083	.149	.048	.399	.005	.932
High school
Fine motor	−.125	.065	.009	.891	−.037	.580
Social participation	−.044	.518	.096	.158	−.033	.622
Mental health	.081	.231	.079	.244	−.022	.748
Handwriting	−.073	.284	−.084	.219	−.009	.894
AT	.110	.105	.150	.027 *	−.122	.070
Self-regulation or EF	−.001	.991	.116	.087	−.091	.178
Literacy participation	.059	.383	.078	.250	−.022	.750
Life skills	−.052	.441	.220	.001 *	−.201	.003 *
Prevocational	.077	.259	.182	.007 *	−.063	.350
Transition	−0.37	.589	.251	<.001 *	−.050	.459

Note. AT = assistive technology; EF = executive function.

* Indicates statistical significance at p < .05.

Most SBOTPs reported spending large portions of their time working with students (M = 49.6%, SD = 18.9). On average, 86.2% (SD = 16.9) of their time with students was spent working with students on IEPs; 5.6% (SD = 8.1), on Section 504 accommodations; and 6.4% (SD = 10.1), on general education. Participants reported spending additional time working on paperwork (78.2%), attending IEP meetings (74.4%), supporting MTSS through problem solving (57.4%), and looking up evidence to support their practice (53.2%), in addition to service delivery. On average, participants reported that 24.6% (SD = 12.9) of their time was spent on paperwork; 15.3% (SD = 9.2), in IEP meetings; and 4.5% (SD = 5.6), looking up resources. Few participants (14.4%) reported engaging in other activities, such as bus, recess, or lunch duty—on average, 1.9% (SD = 12.32) of their time. Open-ended responses revealed other roles that SBOTPs held: in consultation, collaboration, staff meetings, and training of other staff (55.6%); supervising or mentoring certified occupational therapy assistants, SBOTPs, and fieldwork students (23.5%); developing and implementing programs (13%); providing staffing equipment and AT (11%); or engaging in leadership activities (11.8%). One participant explained that they “provide sensory training to aides and personnel staff [and] education on systematic approaches as a building to using the same language throughout grades.”

Discussion

The results of this study describe the roles, service delivery, feedback provision, intervention approaches, and other responsibilities of SBOTPs across settings.

Service Delivery

There were differences between settings related to service delivery. Most SBOTPs in elementary schools reported providing services in therapy rooms, whereas SBOTPs in middle and high schools reported primarily using consultative methods. These findings are consistent with other research indicating that SBOTPs in elementary schools most frequently use pull-out services (Seruya & Garfinkel, 2020). SBOTPs in elementary schools should advocate for service delivery within natural contexts to ensure utilization of evidence-based practices (EBPs; Cahill & Bazyk, 2020; Salazar Rivera et al., 2024). Our findings differ for SBOTPs in middle and high schools who primarily reported using consultative services, although previous research indicates that they used more direct intervention (Rodrigues & Seruya, 2019). This change may reflect a shift from caseload to workload, incorporating more collaborative and consultative methods of service delivery and affording SBOTPs opportunities to focus on environmental adaptations and modifications, and enhance student participation in alignment with existing evidence (Anaby et al., 2015, 2017; Seruya & Garfinkel, 2020). Additional research should consider how SBOTPs are adapting and modifying environments to better support student participation.

Participants expressed a desire to provide integrated services but reported facing logistical challenges (e.g., space and time) that prevented them from doing so. Participants who experienced challenges reported having large caseloads, making it impractical to integrate services simultaneously within a single classroom, which aligned with previous findings (Watt et al., 2024). The data also indicated that SBOTPs lacked dedicated space for therapy services, resorting to using hallway or closet space instead. Participants who were able to integrate services into natural contexts described how MTSS supported them in doing so: providing lessons in general education, engaging in MTSS pre-IEP team meetings, providing behavioral supports, and creating therapeutic environments (e.g., sensory or motor areas). These interventions and strategies are in alignment with previous research (Bissell & Cermak, 2015; Lynch et al., 2023).

Feedback Provision

SBOTPs primarily reported providing feedback through mandated reports or meetings; however, some provided feedback when students made progress, when parents requested it, or through support staff. In open-ended comments, a few SBOTPs shared a desire to provide more regular feedback, which aligns with best practices to support performance (Grajo et al., 2020). Advocacy is imperative to ensure that administrators understand the importance of adequate time to provide feedback and thus support student outcomes and success.

Intervention Approaches

Current literature suggests that handwriting concerns are the primary reason why students are referred to SBOTPs (Cahill & Lopez-Reyna, 2013; Sepanski & Fisher, 2011). Therefore, it is unsurprising that handwriting and fine motor interventions were most reported by SBOTPs in elementary and middle schools. Evidence supports the use of handwriting interventions by SBOTPs to support students’ academic participation and success (Grajo et al., 2020). However, few SBOTPs identify their involvement in literacy interventions (Grajo et al., 2020). Handwriting is considered a component of literacy, but our findings indicate that many SBOTPs fail to recognize their contributions to the full scope of supporting students’ literacy. Research supports SBOTP use of embedded and supplemental creative literacy activities, parent- mediated interventions, and peer-supported interventions to increase reading performance, satisfaction, and literacy participation (Cahill & Beisbier, 2020; Grajo & Candler, 2016; Grajo et al., 2020).

Similarly, although the need for mental health intervention is increasingly being recognized, SBOTPs are not consistently using such interventions. Psychologists, social workers, and counselors have long been considered primary providers for school-based mental health services (Weiss et al., 2021). However, SBOTPs offer unique contributions and should support schoolwide mental wellness initiatives, enhancing social–emotional learning approaches, and supporting educators in adapting their environments in alignment with the existing evidence (Pagano & Cahill, n.d.).

These findings reveal that many SBOTPs are not utilizing EBPs. Advocacy is needed to ensure that SBOTPs incorporate best practice recommendations. It is critical that research examines barriers to and facilitators of the implementation of EBPs in school-based settings and develops the knowledge translation strategies to support the uptake of these interventions.

Factors That Contribute to Interventions

One demographic characteristic that affected intervention choices was the difference between education levels among SBOTPs (bachelor’s, master's or doctorate). This may be due to the additional time and emphasis on EBPs in higher education degrees. Years in practice was correlated with intervention choices, likely because of clinical reasoning skills deepening over time with experience. Finally, caseload size was found to influence intervention selection. It is imperative that SBOTPs demonstrate the many roles and responsibilities they fulfill and advocate for more SBOTPs with appropriate caseload sizes or workload with school administrators (Seruya & Garfinkel, 2020).

Roles

Although participants spent most of their time working with students on IEPs, many still reported fulfilling various roles in schools beyond direct treatment. These roles include

MTSS;

engaging in consultation, collaboration, and training;

developing and implementing programs,

managing equipment and AT inventory; and

taking on leadership responsibilities.

These roles and responsibilities extend beyond daily treatment sessions and should be factored into workloads to ensure an adequate balance of the demands of students’ needs and additional roles and responsibilities (Seruya & Garfinkel, 2020).

Strengths, Limitations, and Future Research

There are limitations and strengths of this research worth noting. This survey was developed by the research team and has not been evaluated for reliability or validity, although expert validation was conducted. Several areas were perceived differently by respondents from what the research team intended or were missing entirely from the survey (e.g., separating out sensory and EF as independent intervention foci; combining literacy and handwriting, despite handwriting being a component of literacy; focusing on family engagement and collaboration; limited emphasis on environmental modifications and adaptations and participation). However, a key strength is the nationally representative sample of SBOTPs, which included representatives from 49 states, although it represents 2% of the total SBOTP population. In future work, researchers should expand on these findings by using reliable and valid measures with more comprehensive lists of interventions and responsibilities to describe the roles of SBOTPs more holistically. Additionally, qualitative research should further elucidate the rationale behind the findings of this study.

Implications for Occupational Therapy Practice

The results of this study have the following clinical implications for occupational therapy practice:

National organizations that support SBOTPs should use this evidence to further define the many roles and responsibilities of SBOTPs to support and advocate for the profession.

SBOTPs should advocate for their role in providing mental health interventions to support children on their caseload and in tiered interventions.

SBOTPs should advocate for their role in literacy promotion, incorporating reading interventions.

School administrations should recognize the multiple roles and responsibilities SBOTPs hold and support them by offering adequate space, resources, and appropriate caseload sizes or transition to a workload model (Seruya & Garfinkel, 2020).

Future research directions should focus on implementation barriers and facilitators to implementing EBPs in school settings to support knowledge translation among practitioners.

Conclusion

SBOTPs provide interventions using a variety of service delivery models. SBOTPs primarily report providing fine motor and handwriting interventions to younger students and life skills interventions for older students. Few SBOTPs reported addressing mental health and literacy participation, despite clear evidence of the need to do so. Feedback was reportedly provided to children and families through required reports or meetings. SBOTPs spend the majority of their time with students on IEPs, but they also hold a variety of other roles. Schools can leverage the contributions of SBOTPs by providing access to more time and resources to better address the needs of student populations, thus ensuring equitable access to academic and social success.

Supplemental Material

Supplemental Information

Supplementary material for Occupational Therapy’s Role in Schools: A Survey of Occupational Therapy Practitioners

Supplementary material, sj-pdf-1-aot-10.5014_ajot.2025.051041.pdf for Occupational Therapy’s Role in Schools: A Survey of Occupational Therapy Practitioners by Deborah Zeitlin, Ashlyn Case, Caroline Clement, Reagan Cook, Halle Tackett, Ryleigh Thomas and Elizabeth K. Schmidt in The American Journal of Occupational Therapy